Can tofacitinib (Xeljanz) be given in the perioperative period?

Tofacitinib Perioperative Management

Tofacitinib should be withheld for at least 7 days prior to elective surgery in patients with rheumatoid arthritis, spondyloarthropathies, psoriatic arthritis, or juvenile idiopathic arthritis, and can be restarted once wound healing is confirmed (minimum 14 days) and there is no evidence of infection. 1

Preoperative Management

Timing of Discontinuation

• Withhold tofacitinib for a minimum of 7 days before elective surgery in patients with rheumatic diseases undergoing total hip or knee arthroplasty 1
• This recommendation is based on evidence showing tofacitinib increases serious infection risk (incidence rate 2.91,95% CI 2.27-3.74) and overall infection risk (RR 5.7,95% CI 1.8-18.1) in non-surgical populations 1
• Despite tofacitinib's extremely short serum half-life, the duration of immunosuppression after discontinuation is not well understood, though indirect translational data suggest host defense returns to normal at 7 days 1

Special Considerations for IBD Patients

• Very limited data exist for perioperative tofacitinib safety in inflammatory bowel disease patients 1
• The single available study in IBD surgical patients reported an increased risk of venous thromboembolic events (VTE), occurring in 13.2% of patients (7/53), with locations including portomesenteric venous thrombus, internal iliac vein, and pulmonary embolism 2
• Prolonged VTE prophylaxis should be considered in IBD patients exposed to tofacitinib perioperatively, potentially extending beyond hospital discharge 1, 2

Postoperative Management

Timing of Resumption

• Resume tofacitinib only after confirming adequate wound healing (generally requiring a minimum of 14 days postoperatively) 1
• Verify absence of both surgical site infection and systemic infection before restarting therapy 1
• Clinical judgment should guide the decision to restart, with careful assessment of wound integrity, suture/staple removal status, and any signs of infection 1

Critical Safety Warnings

Infection Risk

• The FDA has issued a black box warning for all JAK inhibitors regarding increased infection risk, including serious infections 1
• Tofacitinib demonstrates dose-dependent infection risk, with higher rates at 10 mg twice daily compared to 5 mg twice daily 3
• Patients with acute severe ulcerative colitis receiving tofacitinib face additional thrombosis risk beyond baseline disease-related risk 1

Thrombotic Events

• Venous thromboembolism risk is significantly elevated in surgical IBD patients exposed to tofacitinib perioperatively 1, 2
• One case of dural venous sinus thrombosis was reported in a patient receiving tofacitinib for acute severe ulcerative colitis 1
• Consider extended thromboprophylaxis protocols for patients with recent tofacitinib exposure undergoing surgery 2

Clinical Decision Algorithm

Step 1: Identify Surgery Type and Timing

• For elective orthopedic surgery (hip/knee arthroplasty): Plan surgery at least 7 days after last tofacitinib dose 1
• For IBD-related surgery: Withhold tofacitinib and implement enhanced VTE prophylaxis protocols 1, 2

Step 2: Assess Concurrent Medications

• If patient is on corticosteroids >20 mg/day prednisone equivalent, attempt to taper below this threshold before elective surgery when possible 1
• Continue conventional DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) through the perioperative period as these reduce infection risk 4

Step 3: Postoperative Monitoring

• Monitor wound healing daily for minimum 14 days 1
• Screen for surgical site infection and systemic infection before restarting 1
• Maintain heightened vigilance for VTE, particularly in IBD patients, for at least 90 days postoperatively 2

Step 4: Restart Criteria

• All sutures/staples removed 1
• Wound demonstrates adequate healing without dehiscence or drainage 1
• No fever or signs of infection (surgical site or systemic) 1
• Minimum 14 days elapsed since surgery 1

Important Caveats

• The 7-day withholding recommendation may evolve as more clinical experience accumulates with tofacitinib in the perioperative setting 1
• Patients with severe or active disease may be at higher baseline risk for adverse surgical outcomes independent of medication effects 1
• The balance between infection risk from continued therapy versus disease flare risk from discontinuation heavily favors infection prevention, as patients consistently rate infection as more important than flare risk 1